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Showing results for tags 'Safety management'.
Found 143 results
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Content Article
Safer outcomes for people with psychosis
Dorit posted an article in By patients and public
Dorit describes the assessment and subsequent death of her much loved daughter-in-law who died during a psychotic episode having been discharged the previous evening. Her story raises a number of questions: How should families be included in making judgements and assessments about the patient and their well-being? What support do they need to care for a very distressed loved one? Why aren't written care and contingency plans provided to the patient and their family? What more needs to be done to ensure standard practices are in place to protect patients with psychosis? -
Community PostTalking with John Holt, PS Mnager at Birmingham and Solihull CCG today. Would it be helpful to set up a CCG PS Mansger community?
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Content ArticleBuilding on published patient safety research literature, this paper from the OECD, aims to broaden the existing knowledge base on safety lapses occurring in primary and ambulatory care settings.
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Content ArticleHealthcare systems are under stress as never before. An ageing population, increasing complexity and comorbidities, continual innovation, the ambition to allow unfettered access to care and the demands on professionals contrast sharply with the limited capacity of healthcare systems and the realities of financial austerity. This tension inevitably brings new and potentially serious hazards for patients and means that the overall quality of care frequently falls short of the standard expected by both patients and professionals. The early ambition of achieving consistently safe and high-quality care for all1 has not been realised and patients continue to be placed at risk. In this paper published in BMJ Quality & Safety, Amalberti and Vincent discuss the strategies we might adopt to protect patients when healthcare systems and organisations are under stress and simply cannot provide the standard of care they aspire to.
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Content ArticleA written and audio commentary taken from the American news station, wbur. Dr. Ashish Jha discusses the emerging trend for hospitals to spend money opening hotel-like services and argues that too often patient safety takes a backseat to these marketing efforts.
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Content Article
The patient safety leader of the future
Adam Burrell posted an article in Leadership for patient safety
Patient safety made headlines at the recent Patient Safety Learning Conference when Professor Ted Baker (Chief Inspector of Hospital for the CQC) declared that there has been “little progress for NHS patient safety over past 20 years”. One of the interesting discussions at the conference was what do these future directors of patient safety look like? What are the skills and attributes that they will possess? Professor Ted Baker pinpointed three key areas, but what would these look like in practice?- Posted
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Content ArticleAs improvement practice and research begin to come of age, Mary Dixon-Woods in this BMJ feature considers the key areas that need attention if we are to reap their benefits. Mary Dixon-Woods is the Health Foundation Professor of Healthcare Improvement Studies and Director of The Healthcare Improvement Studies (THIS) Institute at the University of Cambridge, funded by the Health Foundation. Co-editor-in-chief of BMJ Quality and Safety, she is an honorary fellow of the Royal College of General Practitioners and the Royal College of Physicians.
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Content ArticleChaired by Robert Francis QC, this Inquiry was set up to examine the commissioning, supervisory and regulatory organisations in relation to their monitoring role at Mid Staffordshire NHS Foundation Trust between January 2005 and March 2009. The Inquiry looked at why the serious problems at the Trust were not identified and acted on sooner, to identify important lessons to be learnt for the future of patient care.
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Community Post
Definition of "Lessons Learned"
Haydn Williams posted a topic in Methodology and guidance: How to do an investigation
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I've been searching for a definition of "Lessons Learned", to inform some internal discussion and a policy review. However, I cannot seem to find one anywhere - I've tried as much NHSI and old NPSA documentation as I can get my hands on, Googled some Trust policies, and done some other searches. The closest I can find is some wording on Knowledge for Healthcare: This seems to be a start, but not necessarily specific to incidents and learning from investigations. I'm also keen to use wording from an organisation which already carries a bit of weight and gravitas, rather than developing our own, if possible. Is anyone aware of anything I might have missed?- Posted
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Content ArticleSafety in aviation has often been compared with safety in healthcare. This article, published in JRSM Open, presents a comprehensive review of similarities and differences between aviation and healthcare and the application to healthcare of lessons learned in aviation.
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Content ArticleFallStop is a quality improvement programme from the Falls Prevention Team at the East Kent Hospitals University NHS Foundation Trust. It was developed in 2016 when they found there was a high rate of falls at one of their hospitals and a failure to learn from incidents. A FallStop Practitioner co-ordinates the programme and delivers training.
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Content ArticleChecklists have become the go-to solution for a vast range of patient safety and quality issues in healthcare. Some see them as a quick and obvious solution to a relatively straightforward problem. For others, they illustrate a failure to understand and address the complex challenges in patient safety and quality improvement. ‘The problem with…’ series covers controversial topics related to efforts to improve healthcare quality, including widely recommended but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution.
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Content Article
Letter from America: A Grand Adventure
lzipperer posted an article in Letter from America
‘Letter from America’ is a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States. The series will cover successes large and small. I share them here to generate conversations through the hub, over a coffee and in staff rooms to transfer these innovations to the frontline of UK care delivery.- Posted
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Community Post
Creating a space to discuss leadership and safety – how can we maximise this opportunity
JULES STORR posted a topic in Other
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My first thought on coming to this community was, is it a bit abstract to be talking about leadership in a sub-community of a patient safety learning platform, when in the real world leadership is part of, or influences so many of the other sub-communities (culture, patient engagement, patient safety learning itself, to name but a few). However, I can definitely see the value in creating a special space to explore and stimulate some cross-fertilisation of ideas and learning on leadership for patient safety. It would be great to get some ideas flowing on how patient safety leaders across all levels of health care could use this community. I’ve found that leadership in the academic literature is sometimes a little vague, it’s common to see “leadership is critical for [X-aspect of] patient safety” written in various ways, but when you try and drill down on concrete examples of what that means it can be frustratingly non-specific. Could we start by stimulating some sharing of tangible real-world examples or vignettes that describe how leadership/leadership development is linked to making care safer or addressing a patient safety-related problem. This may mean infiltrating or drawing on some of the parallel discussions in other sub-forums and seeding the leadership angle into these discussions!- Posted
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Content ArticleHigh numbers of non-urgent attendances at paediatric emergency departments (i.e. attendances for illness that could have safely been treated elsewhere) increases waiting times, inconveniences families, incurs significant costs to the NHS, and reduces the time hospital staff can spend treating severely ill children. This report, produced by the Behavioural Insights Team (BIT) in collaboration with the Connecting Care for Children (CC4C) programme, addresses this issue.
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Content ArticleGetting to grips with human factors – strategic actions for safer care is a learning resource from the Clinical Human Factors Group (CHFG) that recognises the fundamental impact boards have on safety within their organisation. The aim of the resource is to encourage boards to invest time and resource in human factors, by raising awareness of human factors and demonstrating how human factors impact on quality, safety and productivity in healthcare. It is intended to be thought provoking, encouraging board members to think about themselves and their organisation whilst also providing practical actions that boards and individual members can and should be making in this area.
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Content Article
IHI: Leadership guide to patient safety (2006)
PatientSafetyLearning Team posted an article in Clinical leadership
This US White Paper from the Institute of Healthcare Improvement shares the experience of senior leaders who have decided to address patient safety and quality as a strategic imperative within their organisations. It presents what can be done to make the dramatic changes that are necessary to ensure that patients are not harmed by the very care systems they trust will heal them. -
Content ArticleSpreading successful improvement work across the NHS is an essential part of improving health care quality and efficiency. Yet all too often an idea that has been shown to work well in one place is not adopted by others who could benefit from it. This guide from the Health Foundation, intended for those actively engaged in health care improvement, draws on this experience and empirical evidence, to provide practical information about how communications approaches can be used to spread improvement ideas.
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Content Article
National Guardians Office - case referral form.
Claire Cox posted an article in Speak Up Guardians
The National Guardian’s Office is an independent, non-statutory body with the remit to lead culture change in the NHS so that speaking up becomes business as usual. The office is not a regulator, but is sponsored by the CQC, NHS England and NHS Improvement. -
Content Article
An introduction to NHS Digital’s Clinical Safety Team
HannahMcCann posted an article in NHS Digital
We are NHS Digital’s Clinical Safety team and I’d like to tell you more about who we are, what we do and why we do it. -
Community PostI have been thinking recently about the challenges which is posed towards larger trusts with regards to patient safety. Particularly with getting information disseminated to all staff and being reliant on endless emails. I have recently done some work with our Action Card App which has posed its own challenges particularly with physically getting around the Departments, spreading the word, and assisting people on the app itself. What really helped us iare screen savers, twitter and having those key conversations with stakeholders within the trust. I was wondering what everyone elses perspectives were?
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Content ArticleWinter 2017/18 saw an unprecedented demand for health and care support services. Emergency departments bore the brunt of this demand. This report from the Care Quality Commission (CQC) calls for wider action for health and social care services to work together. A joint approach will help the whole health and care system to manage capacity as demand grows. The same approach can encourage early and effective planning - for all periods of peak demand.
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Content ArticleEvery safety-critical industry devotes considerable time and resource to investigating and analysing accidents, incidents and near misses. The systematic analysis of incidents has greatly expanded our understanding of both the causes and prevention of harm. These methods have been widely employed in healthcare over the last 20 years but are now subject to critique and reassessment. This paper from Almaberti et al. Implementation Science published attempts to reconsider the purpose and value of incident analysis and methods appropriate to the healthcare of today.
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Content ArticleThis study assesses the association of increased bed occupancy with changes in the percentage of overnight patients discharged from hospital on a given day and their subsequent 30-day readmission rate. Longitudinal panel data methods are used to analyse secondary care records (n = 4,193,590) for 136 non-specialist Trusts between April 2014 and February 2016.
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Content ArticleContinuous improvement of patient safety: A case for change in the NHS synthesises the lessons from the Health Foundation’s work on improving patient safety.
